Team-Based Intervention to Reduce the Impact of Nonactionable Alarms in an Adult Intensive Care Unit.

BACKGROUND: Nonactionable alarms comprise over 70% of alarms and contribute a threat to patient safety. Few studies have reported approaches to translate and sustain these interventions in clinical settings. PURPOSE: This study tested whether an interprofessional team-based approach can translate and implement effective alarm reduction interventions in the adult intensive care unit. METHODS: The study was a prospective, cohort, pre- and postdesign with repeated measures at baseline (preintervention) and post-phase I and II intervention periods. The settings for the most prevalent nonactionable arrhythmia and bedside parameter alarms were adjusted during phases I and II, respectively. RESULTS: The number of total alarms was reduced by 40% over a 14-day period after both intervention phases were implemented. The most prevalent nonactionable parameter alarms decreased by 47% and arrhythmia alarms decreased by 46%. CONCLUSIONS: It is feasible to translate and sustain system-level alarm management interventions addressing alarm fatigue using an interprofessional team-based approach.

Left ventricular hypertrophy in acute stroke patients with known hypertension.

BACKGROUND: Despite effective treatments, hypertension remains uncontrolled in nearly half of the people with hypertension in the United States. Uncontrolled hypertension leads to end organ damage, such as left ventricular hypertrophy (LVH). To identify reasons for uncontrolled hypertension, we interviewed acute stroke patients with a history of hypertension and evaluated for LVH. METHODS: Using a standardized questionnaire, we collected demographic, socioeconomic, and health-care data in 300 acute ischemic and hemorrhagic stroke patients in one hospital. We also collected relevant clinical data from medical records. We analyzed factors associated with echocardiographic LVH as a marker of uncontrolled hypertension in 190 acute stroke patients with a history of hypertension. RESULTS: Overall, 46% (88/190) of patients had LVH. In univariate analysis, lower household income and self-reported poor adherence to hypertension treatment were significantly associated with increased risk of LVH. In multiple logit modeling, only poor adherence to hypertension treatment remained significantly associated with LVH, odds ratio 1.77 (95% CI: 1.01-3.11), p < 0.05. CONCLUSIONS: In acute stroke patients, poor adherence to hypertension treatment is a significant independent predictor of LVH. A clear reason for poor adherence to treatment is elusive in a large proportion of these patients in our study. Further research is needed to identify and develop strategies to combat the key factors responsible for poor adherence to hypertension treatment.

Paws and Pathogens: A Multidisciplinary Approach Through Bartonella henselae Endocarditis and Hepatosplenic T-Cell Lymphoma.

Bartonella species are gram-negative coccobacilli that are globally recognized as significant pathogens causing zoonotic infections. Among Bartonella species, B. henselae, B. quintana, and B. bacilliformis are prominent pathogens causing infections in humans, often manifesting as infective endocarditis. Bartonella endocarditis can pose diagnostic challenges due to its indolent presentation and limitations of standard microbiological culture techniques to identify the organism. We report a case of a 23-year-old male, who initially presented with the manifestations of hepatosplenic T-cell lymphoma, later diagnosed with blood culture-negative endocarditis caused by B. henselae. The patient had a complicated clinical course including pancytopenia, hepatosplenomegaly, and severe aortic valve regurgitation. Despite negative blood cultures, diagnostic clues included persistent fevers and bicuspid aortic valve with abscess. High Bartonella IgG titers (>1:800) supported the diagnosis. This case underscores the importance of considering Bartonella species in patients with suspected endocarditis, particularly in those with predisposing factors and negative blood cultures. Diagnosis relies heavily on serologic assays due to low sensitivity of conventional culture methods. Treatment involves a multidisciplinary approach with antibiotics and surgical intervention for optimal outcomes. Timely recognition and management are crucial to mitigate the high mortality associated with Bartonella endocarditis, and we hope this article offers insight for clinicians.

Cost effectiveness of radial access for diagnostic cardiac catheterization and coronary intervention.

OBJECTIVES: To evaluate the cost effectiveness of diagnostic cardiac catheterizations (CATH) and coronary interventions (PCI) performed using radial artery (RA) access compared to femoral artery (FA) access. BACKGROUND: CATH and PCI performed from the RA reduce access site complications compared to FA, but can increase procedure duration, and equipment and contrast use. Whether resulting increases in utilization costs are offset by reduced costs of complications is uncertain. METHODS: In all, 6,726 CATH and PCI (RA, 3,368; FA, 3,358) were performed from January 2009 to December 2011. Procedural costs and cost of access site complications were compared for propensity-matched CATH (RA and FA, 1,222) and PCI (RA and FA, 570) throughout a complete transition of the lab from a preferred FA to preferred RA strategy. RESULTS: Adjusted mean total costs were $10 more (95% confidence interval $613 less to $610 more) for RA-CATH versus FA-CATH and $732 less ($1,345 less to $156 less) for RA-PCI versus FA-PCI. The incremental cost per vascular or bleeding complication avoided with RA-CATH was $1,265, whereas RA was economically dominant with lower costs and fewer complications compared to FA for PCI and all procedures. CONCLUSIONS: Radial access for CATH and PCI reduced access site complications and overall costs compared to FA procedures with similar baseline clinical and procedural characteristics, making it an economically advantageous strategy.

Characterization of Sedentary Behavior in Heart Failure Patients With Arthritis.

BACKGROUND: Arthritis is one of the most common comorbidities in heart failure (HF) patients, and is associated with decreased activity levels. Few studies have examined sedentary behavior (SB) in HF patients with arthritis, and little is known about the factors that may influence SB in this population. METHODS: This is a retrospective, secondary analysis using data collected from a randomized control trial. SB was measured by the daily sedentary time collected by accelerometers. Structural equation modeling was performed to examine relationships between key concepts based on social cognitive theory, and elucidate the potential pathways by which demographic, clinical and sociobehavioral factors that influence SB. RESULTS: A total of 101 participants' data were used for this analysis. Participants were mainly female (n = 64, 63%) with a mean age of 70 years (standard deviation (SD) = 12.2) and an average of 13 years of education (SD = 2.3). SB was highly prevalent at baseline (mean value: 21.0 h/day), 3 months (mean value: 20.6 h/day) and 6 months (mean value: 20.8 h/day) in study participants. Factors with statistically significant positive association with sedentary time include age and retirement, while significant negative association was found with current employment. HF self-care efficacy and behavior were also significantly associated with SB. CONCLUSIONS: Most HF patients with arthritis in this study lived a sedentary lifestyle. Additional studies are needed to identify feasible and effective exercise programs for HF participants with arthritis.

Factors Predicting the Utilization of Center-Based Cardiac Rehabilitation Program.

Although cardiac rehabilitation (CR) is clearly beneficial to improving patients' physical functioning and reducing heart disease progression, significant proportions of patients do not complete CR programs. To evaluate the prevalence and predictors of completion of a center-based CR program in eligible cardiac patients, existing data collected from electronic medical records were used. To identify the predictors of CR completion, we used principal components analysis (PCA) and an artificial neural network (ANN) module. Among 685 patients, 61.4% (n = 421) completed the program, 31.7% (n = 217) dropped out, and 6.9% (n = 47) were referred but failed to initiate the program. PCA was conducted to consolidate baseline data into three factors-(1) psychosocial factors (depression, anxiety, and quality of life), (2) age, and (3) BMI, which explained 66.8% of the total variance. The ANN model produced similar results as the PCA. Patients who completed CR sessions had greater extremity strength and flexibility, longer six-minute walk distance, more CR knowledge, and a better quality of life. The present study demonstrated that patients who were older, obese, and who had depression, anxiety, or a low quality of life were less likely to complete the CR program.

Safety and Efficacy of Uninterrupted Apixaban Therapy Versus Warfarin During Atrial Fibrillation Ablation.

Thromboembolic cerebrovascular accident remains a rare but potentially devastating complication of catheter-based atrial fibrillation (AF) ablation. Uninterrupted oral anticoagulant therapy with warfarin has become the standard of care when performing catheter-based AF ablation. Compared with warfarin, apixaban, a factor Xa inhibitor, has been shown to reduce the risk of stroke and major bleeding in nonvalvular AF. With an increase in apixaban use for stroke prophylaxis in patients with AF, there is an increased interest in the safety and efficacy of uninterrupted apixaban therapy during AF ablation. We compared the safety and efficacy of uninterrupted OA therapy with either warfarin or apixaban in all patients who underwent catheter-based AF ablation at the University of Alabama at Birmingham and at Augusta University Medical Center from January 7, 2013, to February 25, 2016. All patients underwent a transesophageal echocardiogram on the day of their ablation to assess for the presence of intracardiac thrombi. All complications were identified and classified as bleeding, thromboembolic events, or other. A total of 627 patients were analyzed as described earlier. There were 310 patients in the warfarin group and 317 patients in the apixaban group. There were 8 complications in the warfarin group and 5 complications in the apixaban group (p = 0.38). There were no thromboembolic complications in either group. In conclusion, the use of apixaban is as safe and effective as warfarin for uninterrupted OA therapy during catheter-based ablation of AF.

Cost-effectiveness of drug-eluting stents versus bare metal stents in clinical practice.

BACKGROUND: Drug-eluting stents (DES) reduce the need for repeat target revascularization (TVR) compared with bare metal stents (BMS) but are more costly. The objective was to evaluate the cost-effectiveness of DES versus BMS. METHODS AND RESULTS: We evaluated clinical outcomes and costs of care over 3 years in 1147 undergoing BMS before the availability of DES and 1247 DES patients at Wake Forest University Baptist Medical Center from 2002 to 2005. Costs for index stenting, TVR, and clopidogrel use were assessed. The 2 groups were well matched for baseline characteristics. Index stenting costs were $1846 higher per patient for DES versus BMS ($1737 more to $1950 more). At 3 years, absolute TVR rates were 15.2 per 100 DES patients and 24.1 per 100 BMS patients, and as a result, cumulative TVR-related costs were $2065 less per patient for DES versus BMS ($3001 less to $1134 less). Including the cost of clopidogrel, the incremental cost-effectiveness ratio per TVR avoided with DES was $4731 through 1 year, $4703 through 2 years, and $6379 through 3 years. CONCLUSIONS: At 3 years, the higher index cost of DES versus BMS was completely offset by lower TVR-related costs. However, because of extended clopidogrel use for DES, the incremental cost-effectiveness ratio per TVR avoided ranged from $4703 to $6379 over 3 years. These unadjusted observational findings provide support for the continued use of DES in routine practice but highlight the important impact of prolonged dual antiplatelet use on the cost-effectiveness of this technology.